https://orcid.org/0000-0002-7408-3289
Abstract
Biliary stents are commonly used for strictures and obstruction, but can migrate distally in up to 20% of cases. While most are identified early, some remain silent for years before presenting with complications. We describe a rare case of a biliary stent that migrated and remained undetected for over 70 years in an 89-year-old woman with a history of cholecystectomy and common bile duct stenting in the 1950s. She presented with acute abdominal pain, nausea, and vomiting. Labs showed leukocytosis, renal dysfunction, and elevated alkaline phosphatase. Computed tomography imaging revealed small bowel thickening, extraluminal gas, and a radiopaque foreign body. Patient was found to have diffuse small bowel diverticulosis with localized perforation and adhesions; segmental resection confirmed diverticulitis with perforation and foreign body reaction around a retained biliary stent. This case highlights an exceptionally delayed complication of stent migration and the importance of comprehensive history-taking when evaluating elderly patients with atypical abdominal symptoms.
Introduction
Biliary stents are widely used in the management of both benign and malignant biliary disease, serving an essential role in relieving biliary obstruction, treating strictures, and facilitating postoperative biliary drainage [1, 2]. Their use has increased substantially with advances in endoscopic and hepatobiliary interventions, and they are generally regarded as safe and effective devices. Nevertheless, stent placement is associated with a spectrum of early and late complications, including occlusion, cholangitis, pancreatitis, perforation, and migration. Distal migration occurs in up to 20% of cases, with the vast majority of episodes developing within the first few months after placement [3, 4]. Migrated stents frequently pass through the gastrointestinal tract without consequence; however, they may also result in significant morbidity, including abdominal pain, bowel obstruction, perforation, or fistula formation, depending on the site of impaction and the extent of surrounding inflammation [5].
Although biliary stent migration is a well-recognized complication, nearly all reported cases are identified within months to a few years after placement [5, 6]. Exceptionally delayed presentations are exceedingly uncommon, and the long-term natural history of retained migrated stents remains poorly characterized. We present an unusual case of an indwelling plastic biliary stent that remained clinically silent for approximately seven decades before migrating to the distal small bowel, where it precipitated recurrent ileal diverticulitis culminating in perforation and the need for emergent surgical resection. This case highlights the extraordinary longevity of an indwelling biliary stent and underscores the importance of considering remote procedural history in the evaluation of unexplained abdominal pathology, even decades after the original intervention.
Case
An 89-year-old woman with multiple medical comorbidities, including diabetes mellitus, coronary artery disease, hypertension, hyperlipidemia, and myelodysplastic syndrome, requiring darbepoetin infusions three months prior to presentation, presented to the emergency department with acute-onset abdominal pain. Her surgical history was notable for an open cholecystectomy with common bile duct (CBD) exploration in the 1950s, during which a plastic CBD stent was left in situ. She had been hospitalized six months earlier for imaging-confirmed ileal diverticulitis, at which time the CBD stent was noted to have migrated into the small bowel. A subsequent surveillance colonoscopy demonstrated sigmoid diverticulosis with an otherwise unremarkable terminal ileum.
The patient reported that the abdominal pain began abruptly on the evening prior to presentation without an identifiable precipitating event and failed to improve with over-the-counter analgesics. She described the pain as nearly identical to her previous episode of ileal diverticulitis and also reported persistent nausea accompanied by two episodes of non-bloody emesis on the morning of presentation. Her last bowel movement occurred that same morning and was non-bloody.
Initial laboratory evaluation demonstrated marked leukocytosis (white blood cell count, 19.4 × 103/μl), elevated blood urea nitrogen (46 mg/dl), and acute kidney injury with a serum creatinine of 2.1 mg/dl. Alkaline phosphatase was mildly elevated at 132 U/L, while the serum lactate remained within normal limits (1.3 mmol/L).
Computed tomography (CT) of the abdomen and pelvis revealed moderately dilated mid-abdominal small bowel loops with marked mural thickening and extensive surrounding inflammatory changes. Multiple adjacent foci of extraluminal gas raised concern for a contained small bowel perforation (Fig. 1). Notably, these inflammatory changes were centered at the site of the patient’s previous episode of ileal diverticulitis. The study also demonstrated the previously documented migrated plastic CBD stent within the distal small bowel in the right lower quadrant (Fig. 2). Colonic diverticulosis was present without evidence of acute colonic diverticulitis.
Axial CT scan of abdomen and pelvis with IV contrast at admission revealing low volume extraluminal free air. Arrow is pointing to the free air visualized in the scan.
Coronal (A) and axial (B) slices of CT scan of abdomen and pelvis with IV contrast at admission. Radiopaque foreign body (encircled) can be visualized in a small bowel loop over the right lower quadrant.
Given the radiographic and clinical findings, the patient underwent emergent exploratory laparotomy. Intraoperatively, extensive intra-abdominal adhesions requiring meticulous enterolysis were encountered, along with diffuse jejunal and ileal diverticulosis. A localized ileal perforation surrounded by dense inflammatory adhesions was identified, and a firm intraluminal foreign body was palpable at the site of the perforated ileal diverticulum. A segmental small bowel resection with primary anastomosis was performed. Histopathologic examination demonstrated marked acute and chronic small bowel diverticulitis with focal fibrosis, acute and chronic serositis, dense serosal adhesions, and a foreign body giant cell reaction localized to the perforation site, confirming chronic inflammation associated with an intraluminal foreign body.
In light of her advanced age, frailty, multiple medical comorbidities, and the complexity of the operation, the patient was admitted to the intensive care unit postoperatively for close hemodynamic monitoring and glycemic management. Although her postoperative recovery was prolonged, it was otherwise uneventful. She was subsequently transferred to the surgical ward, experienced a delayed return of bowel function, and successfully advanced to a regular diet by postoperative day (POD) 10. She was discharged home in stable condition on POD 11. At outpatient follow-up, she continued to recover uneventfully without postoperative complications.
Discussion
Biliary stenting is a well-established therapeutic modality for the management of a broad spectrum of benign and malignant biliary disorders, including irretrievable CBD stones, benign biliary strictures, malignant biliary obstruction, and post-cholecystectomy bile leaks. Although highly effective, biliary stents are intended as temporary devices. Current guidelines recommend that plastic biliary stents be removed or exchanged within ~3 months of placement to minimize the risk of stent occlusion, infection, and migration [7]. In the present case, the stent remained indwelling for more than seven decades, representing an exceptionally prolonged retention period and, to our knowledge, an exceptionally long interval between intraoperative biliary stent placement and clinically significant presentation.
Migration is among the most frequently encountered complications of biliary stenting, occurring in up to 10% of patients. In most instances, migrated stents traverse the gastrointestinal tract uneventfully and are either passed spontaneously or identified incidentally. Clinically significant complications are uncommon and generally occur within months to a few years after placement [5, 6]. Nevertheless, retained migrated stents have the potential to serve as persistent intraluminal foreign bodies capable of inciting chronic inflammation, pressure necrosis, and ultimately perforation, particularly in the presence of pre-existing bowel pathology, such as diverticular disease.
Previous reports have described prolonged asymptomatic retention of biliary stents, although for substantially shorter durations than observed in our patient. Elsharif et al. described an incidentally discovered migrated CBD stent that remained clinically silent for 14 years without associated complications [8]. In contrast, Elsebaey et al. reported that most late complications—including proximal or distal migration, acute cholangitis, and recurrent choledocholithiasis—developed within 1–2 years after placement, emphasizing the importance of timely stent retrieval [9]. These findings reinforce that, although some retained stents may remain asymptomatic for extended periods, they continue to carry the potential for delayed adverse events.
The pathophysiologic mechanism underlying our patient’s presentation is also distinct from previously reported complications. Rather than causing recurrent biliary obstruction, the migrated stent acted as a chronic intraluminal foreign body within the distal small bowel. On histopathologic examination, the stent was associated with a chronic foreign-body reaction at the site of perforation, and may have contributed to the recurrent small bowel diverticulitis and subsequent perforation. This sequence illustrates how a retained biliary stent may remain clinically silent for decades before becoming the nidus for localized inflammation in a susceptible segment of bowel.
Several reports have documented delayed biliary complications years after stent placement. Barai et al. described a patient presenting ~9 years after stent insertion with cholangitis secondary to a stent-stone complex and cholangitic abscess formation [10]. Similarly, Kumar et al. reported proximal stent migration associated with stentolith formation 4 years after placement [11]. In both cases, the retained stent served as a nidus for stone formation within the biliary system. In contrast, our patient developed an entirely extra-biliary complication, with migration into the small bowel resulting in recurrent ileal diverticulitis, chronic foreign body reaction, and perforation nearly 70 years after the index operation.
This case underscores several important clinical lessons. First, retained plastic biliary stents can remain clinically silent for extraordinarily long periods while retaining the capacity to produce severe delayed complications. Second, migrated stents should not be considered benign solely because they are asymptomatic, particularly when they persist within diseased segments of bowel. Finally, this report highlights the importance of obtaining a thorough remote surgical history and maintaining a high index of suspicion for retained foreign bodies when evaluating unexplained abdominal pathology, even decades after the original biliary intervention.
Conflicts of interest
None declared.
Funding
None declared.
